MEDICARE: WELLSTAR COBB HOSPITAL CANCER CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0001X	Radiation Oncology Physician

General Provider Information

NPI Number	:	1366863979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLSTAR COBB HOSPITAL CANCER CENTER LLC

Provider Business Mailing Address
First Line	:	1800 HOSPITAL SOUTH DR
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30106-8114
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 HOSPITAL SOUTH DR
Second Line	:
City	:	AUSTELL
State	:	GA
Zip	:	30106-8114
Country	:	US
Telephone Number	:	770-948-6000
Fax Number	:	770-948-2638

Authorized Official
Title or Position	:	SUPERVISOR PATIENT FINANCIAL SER
Name	:	NELDA CHAMPAGNE
Credential	:
Telephone Number	:	770-907-0554

Provider Enumeration Date	:	12/27/2013
Last Update Date	:	12/27/2013

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